Enrollment Kit -SecureCare (Dental)
X
0
Forms Selected
Clear Selection
Form Name
Effective Date
Current As Of
"Current As Of" signifies the latest date on which a Word & Brown
Team Member confirmed that the Forms/Document available for download represents the most up-to-date and recently
revised version accessible.
This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier’s underwriting guidelines for a complete list of requirements.Please use the latest version of forms.
Our goal is to process your new enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines SecureCare's case submission requirements.
- Employer Master Group Application (signed by owner or officer of the employer group)
- Agent must complete the Producer/General Agent information section on the last portion of the application.
- Employee Enrollment Form for each employee (dates of hire and social security numbers must be filled in)
- (For Employer Sponsored Plans Only) Waiver of Coverage portions of the form must be completed and signed by each employee not enrolling.
- Copy of employer’s most recent state and quarterly unemployment tax report. Please indicate current status of each employee (number of hours worked, date of termination, if no longer employed, or if considered seasonal). Employer must be in business for at least 12 months.
- For Replacement Benefits, please also submit:
- A copy of the present carrier’s summary of benefits or a complete policy. If current plan is a prepaid (HMO) plan, please submit the current schedule of copays
- Present carrier’s last monthly premium bill prior to your group’s effective date with SecureCare Dental
- Include each employee’s effective date of coverage under the prior plan to receive complete take-over credit
- Employer check for first month’s premium. Please make checks payable to SECURECARE DENTAL. Please include the monthly administration fee in the check. The fees are:
- Groups of 2-24 insured: $15.00 per month
- Groups of 25-49 insured: $20.00 per month
- Groups of 50+ insured: $30.00 per month
- All PEO Groups: $50.00 per month
Licensing: Broker appointment must be completed. NOTE: The group will not be approved until licensing is received.
| After approval, prior carrier termination letter must be submitted by the employer or broker. |
For other useful or older documents, please refer to the Forms database.